Spinal tuberculosis (TB) is the most common form of skeletal tuberculosis and remains a leading cause of non-traumatic spinal cord compression in endemic regions. Despite advances in diagnosis and chemotherapy, delayed presentation is common, often resulting in vertebral destruction, deformity, and neurological deficits [1–3].

The disease typically involves the anterior vertebral column due to hematogenous spread, leading to collapse, kyphosis, and formation of paravertebral or epidural abscesses. Neurological impairment arises from mechanical compression, instability, and vascular compromise of the spinal cord [4–6].

While anti-tubercular therapy is the cornerstone of management, surgical intervention is indicated in patients with progressive neurological deficit, spinal instability, deformity, or failure of medical therapy. Advances in spinal instrumentation have improved outcomes by enabling effective decompression and stabilization [2,7].

Neurological recovery following surgery is variable and depends on factors such as baseline neurological status, duration of symptoms, and extent of disease. Among these, preoperative neurological grade has been identified as a key predictor of outcome [8–10].

However, prospective data evaluating the pattern of neurological recovery and its determinants remain limited. The present study aims to assess neurological outcomes and identify predictors of recovery in surgically managed spinal TB patients.

MATERIALS AND METHODS

Study Design

Prospective observational study.

Sample Size

30 patients.

Inclusion Criteria

• Clinico-radiological diagnosis of spinal tuberculosis
• Indications for surgery:
• Neurological deficit
• Instability
• Deformity
• Failure of medical management

Exclusion Criteria

• Non-tubercular infections
• Conservatively managed patients

Parameters Assessed

• Demographics
• Symptom duration
• Level of involvement
• Neurological status (Frankel grade)
• Pain (Denis pain scale)
• Radiological findings

Follow-Up

• Post-op Day 1
• 1 month
• 3 months

Statistical Analysis

• Neurological improvement assessed
• Correlation analysis performed
• p < 0.05 considered significant

RESULTS

Baseline Characteristics

A total of 30 patients were included. The mean age was 34.2 ± 12.1 years, with male predominance (19/30, 63.3%). The thoracic spine was most commonly involved (18/30, 60%), followed by lumbar (9/30, 30%) and cervical (3/30, 10%).

The median duration of symptoms was 2 months (IQR: 1–4). At presentation, 22 patients (73.3%) had neurological deficits.

Neurological Outcomes

At baseline:

• 8 patients (26.7%) had severe deficits (Frankel A–B)
• 14 (46.7%) had moderate deficits (Frankel C–D)
• 8 (26.7%) were neurologically intact (Frankel E)

No significant change was observed in the immediate postoperative period. However, gradual improvement occurred over follow-up.

At 3 months:

• 20/30 patients (66.7%) achieved Frankel Grade E
• 18/22 patients (81.8%) with deficits improved by at least one grade

Pain Outcomes

Pain improved in all patients. The median Denis pain score reduced from 3 (IQR: 2–4) preoperatively to 1 (IQR: 1–2) at 3 months.

Symptom Duration and Outcome

Patients with shorter symptom duration (≤2 months) had:

• More severe deficits at presentation
• Greater improvement after surgery

Patients with longer duration (>2 months) had:

• Better baseline status
• Higher proportion of complete recovery (not statistically significant)

Tables

Table 1. Baseline Characteristics (n = 30)

Table 2. Neurological outcome (Frankel grade)

Table 3. Association of Symptom Duration with Neurological and Pain outcomes

Abbreviations: Δ = change; OR = odds ratio

Figure 1: Distribution of Frankel grades at presentation, immediate postoperative period, and 3-month follow-up demonstrating progressive neurological recovery.

DISCUSSION

The present prospective study demonstrates that surgical management of spinal tuberculosis leads to significant neurological and pain improvement, with recovery occurring progressively over time rather than immediately after surgery.

A key observation was the delayed pattern of neurological recovery, with minimal change in the immediate postoperative period followed by substantial improvement at 3 months. This likely reflects resolution of spinal cord edema, restoration of vascular supply, and gradual neural recovery rather than the effect of decompression alone. Similar temporal patterns have been described previously, suggesting that early postoperative assessment may underestimate final neurological outcome [11,12].

Another important finding was the impact of baseline neurological status on recovery. Patients with severe preoperative deficits demonstrated greater absolute improvement, whereas those with milder deficits were more likely to achieve complete recovery (Frankel Grade E). This highlights that although severe deficits may be reversible, early intervention before advanced neurological compromise offers the best functional outcomes. Preoperative neurological status has consistently been identified as the strongest predictor of outcome in spinal tuberculosis [13–15].

The predominance of thoracic involvement in this study is consistent with established epidemiological patterns, likely related to vascular and biomechanical factors [16]. Pain improvement was observed in all patients, reflecting the effectiveness of surgical decompression and stabilization in addressing both neural compression and spinal instability.

The influence of symptom duration remains complex. In the present study, patients with shorter symptom duration presented with more severe deficits but showed greater postoperative improvement, whereas those with longer duration had better baseline status and higher rates of complete recovery. Although not statistically significant across all measures, this suggests a dynamic relationship between disease progression and neural recovery, as also reported in previous studies [14,17].

From a clinical perspective, these findings support a proactive surgical approach in appropriately selected patients, particularly those with neurological deficits. Additionally, patients should be counseled regarding the gradual nature of neurological recovery, which may extend beyond the early postoperative period.

Limitations

The study is limited by a relatively small sample size and short follow-up duration. Long-term functional outcomes and deformity progression were not assessed. Further studies with larger cohorts and longer follow-up are required.

Conclusion

Surgical management of spinal tuberculosis results in significant neurological recovery and effective pain relief. Neurological improvement is progressive over time, with minimal immediate postoperative change.

Baseline neurological status is the strongest predictor of outcome, with better recovery observed in patients presenting earlier in the disease course. Early surgical intervention in appropriately selected patients improves the likelihood of favorable functional outcomes.

Conflict of Interest

None.

Funding

None.

Ethical approval

The study was approved by the Institutional Ethics Committee, and all procedures were conducted in accordance with the ethical standards of the institutional and national research committee.

Informed consent

Written informed consent was obtained from all patients prior to inclusion in the study.

Author Contributions

All authors contributed substantially to study design, data collection, analysis and manuscript preparation.

Acknowledgment
The authors thank the Department of Neurosurgery and all patients who participated in the study.

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